XP about VBAC after classical incision - Mothering Forums

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#1 of 12 Old 04-16-2008, 11:42 AM - Thread Starter
 
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i posted on the VBAC board but was wondering if any midwives over here had any insight on my situation. here is the post:

bear with me as i am thinking through this.

might it make more sense to do a TOL, even with a classical incision, if the c-section you would need to have is inherently riskier than the "normal" section?

what happened to me was that the OB had to go in to my uterus high up to get my baby out because scar tissue/adhesions and bowel were blocking him from doing a low transverse incision. (this was due to a prior abdominal surgery, nothing to do with birth.) he told me that in any future sections, the dr. (probably NOT him, since he seems to want nothing to do with me again! he wants me to go high risk) would probably need to go in even higher because there will be additional scar tissue from my c-section.

my OB (a very good OB by all accounts, and i liked him) was not even sure after performing my c/s whether he might have perforated some bowel--and told me so hours after my surgery. according to him bowel was "everywhere." apparently my insides are like a minefield for surgeons

anyway, he was visibly shaken after my surgery (i did heal fine, BTW).

anyway, my thought on this is that, if a c-section is so very very scary to do on me, and carries with it extra risks like this, might that not mean a TOL could be more appropriate for me, since if it went well i could avoid another surgery? i worry especially about getting perforated or otherwise injured. i also worry that i could really only have one more c-section, with it getting so much worse each time in terms of scar tissue. (we only plan on one more child, but i wouldn't want an "oops" after that to be catastrophic.)

the flipside, i guess, would be that since a c-section is technically difficult with me, you would not want to have to do it as an emergency--which it might end up being if a labored first and then needed a C.

of course, this is exactly what happened with DD. i labored first, then needed a C because of mec staining and the fact that i'd pushed for 4 hours with no results, and at that point they discovered how damn difficult it was to get her out. they did get her out in time, but it was a little dicey for awhile there.

sorry this is so long, but i'm just trying on this reasoning to see what i think of it. it is all hypothetical at this point because i am not pg or even TTC. i don't want to be until i have some idea of how i might approach this.

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#2 of 12 Old 04-16-2008, 12:54 PM
 
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I think you're right on. Classical incision only raises the risk of uterine rupture up to 1-2% anyway. Of course you should avoid any induction/augmentation of labor. You might have a time finding a supportive doctor, but you make a good case.

BTW, I have a friend named Angela with a daughter named Stella.

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#3 of 12 Old 04-16-2008, 06:47 PM
 
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Originally Posted by momileigh View Post
Classical incision only raises the risk of uterine rupture up to 1-2% anyway.
Where did you get this info? I've always read the risk of rupture with a vertical incision is 4-9%.

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#4 of 12 Old 04-16-2008, 07:04 PM
 
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Well, honestly I got it from my notes which I studied for my final exam. Which I jotted down from a lecture, which was given by someone who doesn't always fact-check. SO, I will attempt to find a better source for this info! (But I don't remember ever reading 4-9% either.)

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#5 of 12 Old 04-16-2008, 09:15 PM
 
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Just so you know that I didn't pull those numbers out of the air

http://www.mayoclinic.com/health/vba...9/PAGE=VB00002

Quote:
Classical incision. This type of incision — also called a high vertical incision — was once used for all C-sections. However, it carries the highest risk of bleeding during labor and of subsequent uterine rupture — 4 percent to 9 percent. It's now used only in emergency situations. VBAC isn't recommended for women who've had a classical uterine incision.

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#6 of 12 Old 04-16-2008, 09:42 PM
 
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OK, I looked it up in Frye and she indicates the rate is between 2 and 4% depending on what study you look at. She says that a "generous" % of uterine rupture for all scars of all shapes is 5%. Here is a link to a page that reproduces what Frye has to say about it:

http://www.gentlebirth.org/archives/vbacfrye.html

Although there is a difference between 1-2% and 2-4%, it is still low enough that especially in this situation, I think it is a good idea to try for a VBAC.

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#7 of 12 Old 04-16-2008, 09:50 PM
 
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Originally Posted by Mrs-Mama View Post
Just so you know that I didn't pull those numbers out of the air

http://www.mayoclinic.com/health/vba...9/PAGE=VB00002
Thanks for the link. I don't know if you realize that on the same page it bluntly states that "home delivery is not appropriate for VBAC." I couldn't disagree more. So I'm thinking they chose the scariest possible stats available. Like I said before, I've never read of a risk approaching anything like 9%. If anyone is getting a rupture rate of 9%, I believe it must be related to management.

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#8 of 12 Old 04-16-2008, 11:10 PM
 
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Thanks for the info, momileigh! I am always interested to read info on VBACing with vertical incisions. I actually have a J-incision so my risk is slightly higher than a classic incision. Also, I've always wondered about VBACing in general after a pre-term c/s. It just seems to me that the risk would be higher anyway, regardless of incision type.

ETA: readytobedone, sorry to hijack your post :

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#9 of 12 Old 04-16-2008, 11:25 PM - Thread Starter
 
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Quote:
Originally Posted by Mrs-Mama View Post
Thanks for the info, momileigh! I am always interested to read info on VBACing with vertical incisions. I actually have a J-incision so my risk is slightly higher than a classic incision. Also, I've always wondered about VBACing in general after a pre-term c/s. It just seems to me that the risk would be higher anyway, regardless of incision type.

ETA: readytobedone, sorry to hijack your post :
you post hijacker, you!

'tis okay.

wanted to add that i have already read the 9-10% estimate is likely flawed because induced/augmented labors were not excluded from it. obviously you wouldn't want induction/augmentation with a classical incision.

i think in studies where this was excluded, you get more of a 2-5% range, never the 9-10% you otherwise hear.

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#10 of 12 Old 04-16-2008, 11:28 PM
 
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Just so you know, Frye does specifically mention J incisions, and doesn't seem to think the risk of rupture is any higher than 5%. But I don't think she specifically addresses preterm c/s in that part of her book, and I don't know if she has done research specific to that topic. I will try looking it up later.

And you're welcome. Thank you for challenging me to actually look it up instead of just pulling a number from my head, which is always a questionable practice!

And I don't think it was too bad of a hijack... I mean, the info should still be interesting to the OP, I think!

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#11 of 12 Old 04-17-2008, 02:54 AM
 
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I think it's important to try to understand why the original c-section was done. Although lowest risk is a successful vaginal birth, the highest risk is a "failed" VBAC that ends in cesearian. Imagine two hypothetical women, one had a vaginal birth, then a c-section for breech - her next baby is likely to come vaginally just fine. The other hypothetical woman has a fibroid that blocks some of the pelvis, and was unable to push out her baby - she has a much lower risk of having her baby come out vaginally - after all, she tried to do it in a very similar situation before.

I think it would be nice to have a good long talk with a VBAC supportive doctor about your operative report, and labor history and see whether the scar tissue was perhaps in the way of your daughter arriving and likely to be a concern. Your idea about avoiding more surgery is an excellent one. But if there is (totally hypothetically speaking) only a very small chance of success, then perhaps TOL isn't advisable.

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#12 of 12 Old 04-18-2008, 06:01 PM - Thread Starter
 
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Quote:
Originally Posted by Apricot View Post

I think it would be nice to have a good long talk with a VBAC supportive doctor about your operative report, and labor history and see whether the scar tissue was perhaps in the way of your daughter arriving and likely to be a concern. Your idea about avoiding more surgery is an excellent one. But if there is (totally hypothetically speaking) only a very small chance of success, then perhaps TOL isn't advisable.
i've wondered the same thing about whether the scar tissue was why she wouldn't come. in my heart i don't really think so because i dilated steadily, easily, and fully in about 11 hours. most things i have read say that scar tissue will also interfere with proper contractions and thus dilation. but i don't really know.

i've talked to the OB about why she wouldn't come out and he said i had a pretty small pelvis --he also said we'll never really know and it doesn't matter because i will never birth vaginally

but he did also say my past surgery, etc. most likely had nothing to do with her not coming out.

DD was average sized with a small head (13 3/4 inches).

because he pulled her out close to the top of my uterus, feet-first, he never saw how her head was positioned inside me. so we don't know anything that way, either. i did have some back labor throughout.

the only notable thing i know is pushing hurt like crap on the left side of my pelvis (think horrible burning!), which is where DD was always tucked, on the left side of my uterus, and her left ear was folded in half for the first 24 hours of her life. no molding. she got to 0 station (was there before i went into labor), no further. i have thought could be asynclitic head? but i don't really know much about that.

anyway, my feeling is that any doctor who doesn't want me to VBAC (which is probably almost every doctor) is going to say i can't push babies out, whether they think so or not, because it's more good support for why not to "allow" a TOL. so i get what you're saying about talking to someone, but i don't really trust anyone i have yet met to tell me the truth about why they think the pushing didn't work for me.

ETA: i don't mean to sound dismissive of your advice! i guess i do need to talk to someone, but how do you find a truly VBAC friendly doc? the hospital where i birthed does VBAC and my OB does VBACs, too, but no one i know of does VBAcC!

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